GNEw9010z** SERV0010 GNEwGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEwepa@@<4D_c\bleGNEw9010GNEw 'GNEw9010 Page ]ZX*Page number0002 Re:  ] JBO5&  DOB: ] JBO5 TRPweparator 4D_enable 4D_checkableTRPw0010IRPXIRPUVT$m@dXXIRPWNorth Lakes - Admin Room on LU 4dXXA4+FNIwDoConfirmq@1FNIw0010 ?MRPwMRPw4010/= +ee+H++HHH,?XIPw XIPw301BORPweparator 4D_enable 4D_checkablePRPw1010TNFw TNFw0010!Times New RomanArialSymbolCalibriCambriaTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman BalticTimes New Roman (Vietnamese)Arial CE Arial Cyr Arial Greek Arial TurArial (Hebrew)Arial (Arabic) Arial BalticArial (Vietnamese) Calibri CE Calibri Cyr Calibri Greek Calibri TurCalibri BalticCalibri (Vietnamese) Cambria CE Cambria Cyr Cambria Greek Cambria TurCambria BalticCambria (Vietnamese)LTSwNormalor 4D_enable 4D_checkableLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman@@@@@@h@D@ @@@@@l@H Metro North Hospital & Health Service Central Patient Intake PAEDIATRIC REFERRAL FORM @H@l@@@@@ @D@h@@@@@ CPI, Aspley Community Health Centre, 776 Zillmere Road, Aspley, Qld, 4034 @@@@d@@@@@@@@h@D@ @Phone  1300 364 938 Fax:  1300 364 952 @@ @D@h@@@@@@@@d@@@  Information and resources are available at: http://www.health.qld.gov.au/metronorth/refer/  Please direct an acutely unwell patient to the Emergency Department @@@@@@h@D@ @@@@@l@H  Secure electronic transfer to: Metro North Central Patient Intake (MQ40290004P) @@@@d@@@@H@l@@@@============================================================================== Specialty referred to:   @@ @D@h@@@@@@@@d@@@Named referral (if different from above): @@ @D@h@@@@@@@@d@@@Referral date: ]zzlJBO5ZNKOT@NRTX& Show_CurrentDatew@ Length of referral:  Referrals are shared with other specialists to ensure patients are seen as quickly as possible  ============================================================================== Patient Details  Re: ] JBO5&  @Z@#@@@@Preferred name: @@@@#@ZDOB: ] JBO5  Age: ] JBO5%    Se x: ] JBO5 @Q@@Address: ] JBO5 ] JBO5H ] JBO5 ] JBO5, ] JBO5+  @@@@QPatient Home Phone: ] JBO5 Patient Mobile Phone: ] JBO5J   Parent/Guardian/Agency name: Relationship to patient: Parent/Guardian/Agency mobile or contact number: Postal Address  (if different from above):  Medicare: ] JBO5' ] JBO5  Aboriginal or Torres Strait Islander origin: @@Interpreter Required: >ңBңBCCPreferred Language:  @@ ============================================================================== Primary Reason for Referral    Detailed history or comments: ============================================================================== Patient History Relevant Medical and Surgical History: Medication List: ]ddVJBO5DNKOT@NRTX Show_Scriptsw Allergies/ Adverse Events (including medications / food / latex / environment eg grasses): ]ffXJBO5FNKOT@NRTX Show_Allergies. Immunisation Status: Relevant Family History: What additional documents have been faxed or sent: Recent Investigations: ============================================================================== Referring Doctor Details Doctor : ] JBO5    Provider No.: ] JBO5 !   Doctor Address: @@ @@@@M@U@7 ]vvhJBO5VNKOT@NRTX" Write_HandleField    Phone: ] JBO5   Fax: ] JBO5  @@@ @@@M@U@7 Patient s Usual G.P.  (if different from above): Is anyone else involved in the care of the patient?:  Verification   Signed electronically: ] JBO5  >N CN CCC !MNHHS Paediatric Referral v6.2 Genie 180701 ============================================================================== !